Battling Diarrhoea: Repackaging ORS & Zinc

After pneumonia, diarrhoea is the second biggest cause of deaths of children under five years old, responsible for 15 per cent of child deaths in low income countries in 2008 (World Health Organization, 2012). Diarrhoea accounts for nearly 760,000 deaths per year and only one third of children with diarrheal diseases receive the recommended treatment (UNICEF, 2012).

Diarrhoea usually elapses within three or four days but because too much liquid and nutrients from the body are lost through stools and vomiting, diarrhoea leaves the body dehydrated and malnourished if not treated. The most likely cause of death is therefore dehydration. These findings highlight the importance of ensuring that children receive adequate treatment. The treatment guidelines for an occurrence of diarrhoea in children as outlined by WHO include zinc supplementation and oral rehydration salts (ORS). Zinc is prescribed during an episode of diarrhoea to reduce the incidence in the following 2–3 months and because it results in a 25 per cent reduction in duration of acute diarrhoea and a 40 per cent reduction in treatment failure or death in persistent diarrhoea (Zulfiqar A Bhutta, 2000). ORS helps hydrate the child, replacing the lost salts and water.

Diarrhoea is the second biggest cause of deaths of children under five years old, responsible for 15 per cent of child deaths in low income countries in 2008.

Only one third of children with diarrheal diseases receive the recommended treatment.

THE PROBLEM

The POUZN project managed by USAID and UNICEF (USAID, 2010) revealed that caregivers’ treatment of the childhood diarrhoea is often incomplete due to confusion as to the correct usage of both ORS and Zinc. Often caregivers are not given instructions on how to treat a child suffering from diarrhoea with the resources made available unless they can read the language printed on the sachet/blister pack. There is also confusion on the instructions for the ORS treatment because although each ORS sachet has treatment instructions printed on the rear of the pack, each manufacturer provides different instructions.

The resulting problem is that caregivers do not comply with the adequate treatment for the child’s diarrhoea. There are often cases where the child’s 10 day programme of zinc treatment is incomplete due to misinformation about the treatment instructions or due to the misconception that zinc should only be given with ORS. The ORS treatment suffers from similar confusion, where it is often neglected because caregivers do not know that ORS should be given at the same time as zinc tablets.

INTRODUCING THE SOLUTION

The challenge was to find a solution that would ensure the adequate treatment including the complete 10 day programme of zinc tablets and the simultaneous ORS treatment.

The purpose was to reduce the confusion about how to treat diarrhoea with both medicines, which arose because UNICEF supplied both products separately, and each of them had their respective instructions. The investigation into possible solutions led to the observation that bundling the two products in one package would increase their combined use, as the benefits of their use would be more evident. Therefore, the proposed solution aimed to:

Bundle zinc and ORS together to ensure caregivers received both medicines.

Provide a leaflet with improved instructions that include both treatments.

Challenges

There were two main challenges in developing a co-packaged solution of zinc and ORS. The first main challenge was that the supply of zinc and ORS came predominantly from different suppliers, which made it difficult for one supplier to manufacture and bundle the two medicines. Research and communication with various suppliers led to the identification of two UNICEF suppliers, who manufactured both medicines and could supply the co-packaged product. However, in order to increase the supply of the co-packaged product, actions had to be taken to communicate with other suppliers and help them collaborate. These efforts resulted in two more suppliers being able to supply the co-packaged product. This issue highlighted the importance of research as well as communication with UNICEF suppliers in order to ensure cooperation and collaboration.

The second challenge faced in distributing the two medicines in one package was the distinct regulations for each of the two medicines. ORS is an established over-the-counter medicine, while zinc was at the time predominantly a prescription medicine. Through advocacy and the inclusion of zinc in the priority medicines list, the co-packaging challenge is being addressed by making zinc more widely available as an over-the-counter medicine. Again, the importance of collaboration with other organizations proved to be very valuable in this process.

The Process

The zinc and ORS medicines needed to be co-packaged in order to increase the caregivers’ compliance with the recommended course of treatment. To achieve this, an investigation of suppliers of the two medicines was conducted, and in September 2012 UNICEF met with several of them to suggest the changed product. Ongoing collaboration took place with suppliers until July 2013. The final co-packaged solution includes two different packs; one pack with 2 ORS sachets for 1 litre and 1 blister strip of 10 Zinc tablets of 20 mg, and another pack with 4 ORS sachets for 500ml and 1 blister strip of 10 Zinc tablets of 20 mg. Both packs contain a depictive care giver instruction leaflet. The co-packaged product is now available for purchase and entered the UNICEF tender process in the third quarter of 2013.

This innovation challenge was first posted on UNICEF innovation web page and suppliers, partners, universities, NGOs and other interested parties were requested to provide feedback. UNICEF received positive feedback from various parties including Cola Life. The information leaflet depicting the treatment process was created through collaboration with the Danish Technical University (DTU). Students were presented with the challenge of finding a co-packaged solution and depictive leaflet. An example of a depictive instruction leaflet can be seen in Figure 2.

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